UNIVERSITY OF ILLINOIS AT CHICAGO
Exposure Control Plan for
Bloodborne Pathogens

Table of Contents

1.0 Purpose and Scope

2.0 Definitions

3.0 Methods of Compliance

3.1 Universal Precautions
3.2 Engineering and Workplace Controls

3.2.1 Certified Biological Safety Cabinets

3.3 Safe Work Practices

3.3.1 Body Washing

3.3.2 Eating, Drinking, Smoking

3.3.3 Contaminated Equipment

3.3.4 Contaminated Containers

3.3.5 Authorized Personnel

3.3.6 Spills

3.3.7 Infectious Waste Disposal
4.0 HIV and HBV Research Laboratories and Production Facilities
4.1 Vacuum Lines
4.2 Autoclave

4.3 Sinks and Eyewash Stations

4.4 Hypodermic Needles

4.5 Hazard Warning Signs

4.6 Physical-Containment Devices

4.7 Transfer of HIV and HBV

4.8 Additional Requirements
5.0 Personal Protective Equipment
5.1 Employer's Responsibilities
5.2 Employee Declination

5.3 Gloves

5.4 Masks, Eye Protection, Face Shields

5.5 Gowns, Aprons, and Other Protective Clothing

5.6 Head Wear Shoes

5.7 Garment Removal
6.0 Communication of Hazards to Employees
6.1 Labels
6.2 Color-Coding

6.3 Signs
7.0 Contaminated Sharps-Discarding and Containment

8.0 Other Regulated Waste- Disposal and Containment

8.1 Containment
8.2 Disposal
9.0 Housekeeping Practices

10.0 Laundry Practices

11.0 Hepatitis B Vaccine

11.1 Declination of the Hepatitis B Vaccine
12.0 Procedure for Staff Occupationally Exposed To Blood or Body Fluids

13.0 Collection and Testing of Blood for HIV and HBV Serological Status

13.1 Collection and Testing of Source Individual's Blood for Serological Status
14.0 Training
14.1 Additional Training for Employees in HIV and HBV Research Laboratories and  Production Facilities
15.0 Information
15.1 Personal Protective Equipment
15.2 Hepatitis B Vaccine
16.0 Record Keeping
16.1 Medical Records
16.2 Training Records

16.3 Manifests
Appendices
17.1. Department Listing of Tasks and Procedures for List B
17.2. Department Schedule for Cleaning and Decontamination

17.3. List and Locations of Available Training Materials
1.0 Scope and Responsibility

Through its standard, Occupational Exposure to Bloodborne Pathogens (29 CFR 1910.1030), the Occupational Safety and Health Administration (OSHA) requires a written Exposure Control Plan.  The purpose of this plan is to insure that all University personnel are provided with a safe workplace and are made aware of potential workplace hazards resulting from exposure to blood and other potentially infectious materials.

This plan applies to all faculty, staff, and student employees who are occupationally exposed to blood or other potentially infectious materials.

The University is committed to providing a safe workplace for its students as well as its staff.  Student-employees will be treated as university staff members with respect to the following policies.

Students who are not employees are also required to comply with these policies.  The University will not assume any financial responsibility for expenses incurred by students who are not employees of the University, as a result of their compliance efforts (e.g. purchase and maintenance of personal protective equipment, cost of Hepatitis B vaccination etc.).

Each department or unit head who has one or more employee subject to this exposure control plan is responsible for insuring that each employee receives proper training and that all other requirements of this exposure control plan are followed.

Each department will be responsible for filling in Appendix A-1 with a list of all tasks and procedures or groups of closely related tasks and procedures in which occupational exposure occurs and that are performed by employees designated as being on List B of the List of Personnel Occupationally Exposed to Blood or Other Potentially Infectious Materials. This list is to be updated annually and is located in the Environmental Health and Safety Office, Health and Safety Section, 245 PSB (Bldg. 963, Rm. 245).

This plan is to be updated and reviewed annually and is available to all employees at their department office.

2.0 Definitions

For the purpose of this plan the following definitions shall apply:

Blood - human blood, human blood components, and products made from human blood.

Bloodborne Pathogens - pathogenic microorganisms that are present in the human blood and that can cause disease in humans.  These pathogens include but are not limited to hepatitis B (HBV) and
human immunodeficiency virus (HIV).

CFR - means Code of Federal Regulations

Clinical Laboratory - a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious material.

Contaminated - the presence of blood or the reasonably anticipated presence of blood or other potentially infectious materials (on a surface or item).

Contaminated Laundry - which has been soiled with blood or other potentially infected material or which may contain sharps.

Contaminated Sharps - any contaminated objects that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wire.

Decontamination - the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens (on a surface or item) to the point where they are no longer capable of transmitting infectious particles; and the surface or item is rendered safe for handling, use, or disposal.

Engineering Controls - (e.g., sharps disposal containers, self sheathing needles) controls that isolate or remove the bloodborne pathogen hazards from the workplace.

Exposure Incident - a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

Handwashing Facilities - a facility providing an adequate supply of running potable water, soap, and single use towels.

HBV - hepatitis B virus.

HIV - human immunodeficiency virus.

Needleless Systems- a device that does not use needles for: the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established, the administration of medication or fluids, or any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

Occupational Exposure - reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or any other potentially infectious material that may result from the performance of an employee's duties.

Other Potentially Infectious Materials - includes the following: (1) human body fluids: cerebrospinal, synovial, pleural, pericardial, peritoneal, amniotic, semen, vaginal secretions saliva in dental procedures; all body fluids, secretions, and excretion except sweat; all body fluids in situations when it is difficult to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human living or dead; (3) HIV-containing cell or tissue culture, organ culture, and HIV or HBV-containing culture medium or other solutions; and (4) blood, organs or other tissues from experimental animals infected with HIV or HBV.

Parenteral - piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

Personal Protective Equipment - is specialized clothing or equipment worn by an employee for protection against a hazard.  General work clothes (e.g. uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Production Facility - is a facility engaged in industrial-scale, large volume (10 liters or more) or high concentration production of HIV, HBV, or HCV.

Regulated Waste - liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Also called Biohazardous Waste.

Research Laboratory - a laboratory producing or using research laboratory scale amounts of HIV or HBV.  Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

Sharps Injury Log - a log for the recording of percutaneous injuries from contaminated sharps. The information in the sharps injury log shall be recorded and maintained in such manner as to protect the confidentiality of the injured employee. This log will contain: the type and brand of device involved in the incident, the department or work area where the exposure incident occurred, an explanation of how the incident occurred, and other items of information deemed relevant by the University Health Service.

Sharps with Engineered Sharps Injury Protections - a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.

Standard Precautions - this concept synthesizes the major features of Universal Precautions and Body Substance Isolation and applies them to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. Standard Precautions apply to: blood, all body fluids, secretions, and excretions regardless of whether or not they contain visible blood (the only exception is sweat), non-intact skin, and mucus membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the hospital and clinic setting.

Sterilize - the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

Universal Precautions - is an approach to infection control.  According to the concept of Universal Precautions, all human blood and certain other human body fluids are treated as if known to be infected with HIV, HBV, or other bloodborne pathogens.

Work Place Controls - that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting the recapping of needles by a two-handed technique).

3.0 Methods of Compliance

The University will comply with the standard by observing a number of practices.

3.1 Universal Precautions

The University will continue the practice of Universal Precautions, as adopted August 1989 and as amended, to prevent contact with blood or other potentially infectious materials.

3.2 Engineering and Workplace Controls

Engineering and work practice controls shall be used to eliminate or minimize employee exposure.  Personal protective equipment shall be worn in situations where the potential for exposure remains after the implementation of engineering controls.

All procedures involving blood or other potentially-infectious material will be performed in a manner which minimizes splashing, spraying and spattering and generation of these substances.

Mechanical pipetting devices are used for all liquid transfers.  Mouth pipetting or mouth suctioning of blood or other potentially infectious material by mouth is prohibited.  Pipette tips are disposed of in biohazard sharps containers.

Contaminated needles or other contaminated sharps shall not be bent,  recapped, sheared, broken, or removed manually.  A mechanical device such as a self-sheathing needle or a one-handed technique may be used to recap or remove needles.  Immediately, or as soon as possible after use, sharps will be placed in containers that are puncture resistant, leak proof on the sides and bottom, and properly labeled or color coded

Specimens of blood or other potentially infectious materials will be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping. The containers should be labeled "Biohazard" and should be either red or red-orange in color.

3.2.1 Certified Biological Safety Cabinets

Biological safety cabinets (Class I, II, III), or other combinations of personal protection or other physical containment devices, must be used for all activities with potentially infectious materials that pose  a threat of exposure to droplets, splashes, spills, or aerosols.

Biological Safety Cabinets must be certified when installed, whenever they  are moved, and at least annually by a certifier of a biosafety cabinet with an active NSF 49 certification. (link to Biosafety Cabinet Certifiers)

3.3 Safe Work Practices

3.3.1 Body Washing

Employees will wash their hands or any other skin surface with soap and water; or flush the mucous membranes with water immediately or as soon as possible following contact with blood or potentially infectious materials.

Employees will wash hands immediately or as soon as possible following removal of gloves or other personal protection equipment.  Antiseptic hand cleaners or towelettes, in conjunctions with clean cloth or paper towel, must be used if hand washing facilities are not available.

Employees  wash their hands for at least 20 seconds after handling infectious materials.

HIV and HBV research laboratories must have an eye wash facility readily available for eye washing in each laboratory.

All labs in which potentially infectious materials are handled must have accessibility within 10 seconds to a separately plumbed eyewash that can deliver a minimum of 0.4 gallons per minute of potable water for a period of 15 minutes.

All labs in which potentially infectious materials and hazardous materials are handled must have accessibility within 10 seconds to safety shower that can deliver a minimum of 20 gallons per minute of potable water for a period of 15 minutes.

3.3.2 Eating, Drinking, Smoking

Eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses and gum chewing are prohibited in areas where there is a reasonable risk of occupational exposure.

Food or beverages will be consumed only in safe designated areas.

Food and drink must not be kept in refrigerators, freezers, or cabinets or on countertops, shelves and benchtops where blood or other potentially infectious materials are present.  These refrigerators must have biohazard stickers and "No Food/ No Beverages" signs.

Smoking is not permitted.

3.3.3 Contaminated Equipment

Equipment which has been contaminated with blood or other potentially-infectious materials will be decontaminated before being serviced or shipped unless it can be shown that decontamination of the equipment is not feasible.

Equipment, or portions thereof, which have not been decontaminated require a warning label be affixed by appropriate personnel.

The University will convey all information to all affected employees.  The servicing representative and or manufacturer's representative as  appropriate prior to handling servicing or shipping so that appropriate precautions are taken.

3.3.4 Contaminated Containers

If outside contamination of the primary container occurs, the generator will place the primary container within a secondary container which prevents leakage during handling processing, storage, transport or shipping and which is labeled or color coded according to the same requirements as the primary container.

3.3.5 Authorized Personnel

Only personnel authorized by the laboratory supervisor are allowed in the laboratory.  Casual visitors (e.g., family members, tour groups) are discouraged. Non-laboratory personnel are closely supervised, and appropriate protective measures and/or equipment (e.g.., clothing) are used to ensure that they do not cause a hazard to themselves or the laboratory staff.  Service and maintenance personnel are not permitted to enter a biohazard area until (1) the laboratory's safety requirements are reviewed (2) the instrument is  decontaminated and  (3) appropriate personnel protective equipment is used and worn.

Laboratory doors will remain closed when work is in progress.  Access to animal houses must be kept closed when work is in progress.  Access to animal houses will be restricted to authorized persons.

3.3.6 Spills

All spills of blood and other potentially infectious materials must be immediately contained and cleaned up by the appropriate professional staff or others properly trained or equipped to work  with potentially infectious materials.

A spill or accident that results in an exposure incident must be  immediately reported to the employees supervisor and health evaluation sought from University Health Services or Emergency Service Department when University Health Services is closed.

3.3.7 Infectious Waste Disposal

The University will continue to follow the practices and procedures for disposing of infectious waste as outlined in Hospital Environmental Services Policy and Procedure Manual (#0400).  This document can be found in the Hospital Environmental Services Office, 500 UIH (Bldg. 494, Rm. 506).

4.0 HIV and HBV Research Laboratories and Production Facilities

The following requirements apply to research laboratories and production facilities engaged in the culture, production, concentration, experimentation, and manipulation of HIV and HBV.  They do not apply to clinical or diagnostic laboratories engaged solely in the analysis of blood, tissue or organs.  These requirements apply in addition to the other requirements of this exposure control plan.

4.1 Vacuum Lines

Vacuum lines in HIV and HBV research laboratories and production facilities must be protected with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters, or filters of equivalent or superior efficiency.  These filters must be checked as soon as necessary by appropriate personnel.

4.2 Autoclave

HIV and HBV research laboratories and production facilities must have an autoclave readily available for decontaminating waste.

4.3 Sink and Eyewash Stations

HIV and HBV research laboratories and production facilities must have a sink for washing hands and a readily available eyewash facility.  The sink will be foot, elbow, or automatically operated and will be near the exit door of the work area.

4.4 Hypodermic Needles

The use of hypodermic needles and syringes in HIV and HBV laboratories is permitted only for (1) parenteral injection and (2) aspiration of fluids from laboratory animals and diaphragm bottles.  Only needle-locking syringes are permitted for the injection and aspiration of potentially infectious materials. If appropriate, sharps with engineered sharps injury protections, or needleless systems shall be provided, and used in laboratory or clinical situations which may involve an exposure to a bloodborne pathogen.

4.5 Hazard Warning Signs

When potentially infectious material or infected materials are present in the work area or containment module, a hazard warning sign incorporating the universal biohazard symbol will be posted on all access doors.  The hazard sign will comply with section 6.3 of this plan.

4.6 Physical-Containment Devices

All activities involving potentially infectious materials will be conducted in biological safety cabinets or other physical-containment devices within the containment module.  No work with these potentially infectious material will be conducted on an open bench.

4.7 Transfer of HIV and HBV

For the purposes of this plan both HIV and HBV will be considered etiological agents as defined by the Department of Health and Human Services.  Transfer of HIV or HBV from a University research laboratory or production facility to another researcher, university or other facility will comply with the regulations pertaining to the packaging and shipment of etiological agents as described in 42 CFR 72.3.

4.8 Additional Requirements

For additional equipment and safe work practices that are specifically required in HIV and HBV research laboratories and production facilities, refer to 29 CFR 1910.1030(e) which can be found on the internet at http://www.osha.org.

5.0 Personal Protective Equipment

All University personnel will use barrier precautions (i.e., gloves, masks, lab coats) to prevent exposure to the skin and mucous membranes (eyes, nose, mouth) when contact with blood or other potentially infectious material could be anticipated.

Personal protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time during which the protective equipment will be used.

Personal protective equipment will be utilized when working with patients and potentially infectious materials. Disposable protective care gloves will be used during handling of contaminated disposable waste items.

The mucous membranes (eyes, nose, and mouth) will be protected by mask and safety glasses or face masks when there is a likelihood of spatters or splashes from blood or body fluids.

5.1 Employer's Responsibilities

Personal protective equipment will be provided at no cost to the employee.  Personal protective equipment will include the following: Gloves, laboratory coats, face shields, or masks and eye protection, mouth pieces, resuscitation bags, pocket masks or other ventilation equipment.

Appropriate personal protective equipment in appropriate sizes will be readily accessible in each work area.

Cleaning, laundering, repair, replacement or disposal of personal protective equipment will be provided at no cost to the employee.

Hypoallergenic gloves, glove liners, powderless gloves and other similar alternatives will be readily accessible to employees who are allergic to gloves normally provided.

Employees are forbidden to take contaminated protective equipment or garments home for cleaning.

5.2 Employee Declination

Personal protective equipment will be used for all occupational exposure situations; however, the employee may temporarily or briefly decline the use of the equipment in the following scenario; "Under rare and extraordinary circumstances, the employee uses his/her professional judgment that, in a specific instance, its use would have prevented delivery of health care or public safety services or would have posed an increased hazard to the safety of the employee."

Situations in which personal protective equipment was temporarily or briefly declined will be investigated and documented to determine if changes can be instituted to prevent future occurrences.

5.3 Gloves

Gloves will be worn when it can be reasonably anticipated that the employee may have contact with blood, other potentially infectious material, mucous membranes, and non-intact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.

Disposable gloves (single use) will always be removed inside out aseptically and replaced as soon as practical when: (1) visibly contaminated, (2) torn, (3) punctured or when the ability to function as a barrier has been compromised.  Disposable gloves will not be washed or decontaminated for reuse.

Utility gloves may be decontaminated for reuse (if the integrity of the gloves is not compromised). They must be discarded if they are cracked, torn, punctured, or exhibit any other signs of deterioration.

Gloves are to be worn for all phlebotomy procedures.

5.4 Masks, Eye Protection, Face Shields

Masks or protective eye wear combinations (goggles or glasses with solid side shields), or face shields which protect all mucous membranes will be worn when performing procedures that are likely to generate splashes, spray, splatter or droplets of blood or other potentially infectious materials.

5.5 Gowns, aprons, and Other Protective Clothing

Gowns, aprons or other protective body covering will be worn in all occupational exposure situations.

5.6 Head Wear, Shoes

Surgical caps or hoods and/or shoe covers will be worn in instances where gross contamination can be anticipated (e.g., autopsies, orthopedic surgery).  Open-toed or perforated shoes are prohibited.

5.7 Garment Removal

If a garment(s) is penetrated by blood or other potentially infectious materials, the garment must be removed immediately or as soon as feasible.  If disposable, the garment shall be disposed of appropriately.  If the garment is reusable, it will be treated with an appropriate, approved disinfectant as soon as feasible, or laundered as outlined in the University of Illinois Hospital Laundry Policy and Procedure Manual.

Personal protective equipment will be removed prior to leaving the work area.

6.0 Communication of Hazards to Employees

6.1 Labels

Warning labels will be affixed to containers of regulated waste and to refrigerators and freezers containing blood or other potentially infectious materials.

Labels will be fluorescent orange or orange-red or predominantly so, with lettering or symbols in a contrasting color.

Labels must include the biohazard legend.

Required labels will be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.

Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.

Contaminated equipment must be labeled in accordance with the requirements mentioned above and must state which parts of the equipment remain contaminated.

6.2 Color-Coding

Red bags or red containers may be substituted for labels.

The labeling or coloring-coding system is required when the specimens leave the facility of origin.

6.3 Signs

The employer is responsible for obtaining and posting biohazard signs at the entrances to clinical and research laboratories as well as HBV and HIV Research laboratories.  The signs shall be fluorescent orange-red or predominantly so, with lettering or symbols in a contrasting color.  The Health and Safety Section of the Environmental Health and Safety Office shall monitor compliance with these posting requirements.

Signs must bear the biohazard legend with the name of the infectious Agent, if known, special requirements for the area, and the name and telephone number of laboratory director or other responsible persons.

7.0 Contaminated Sharps-Discarding and Containment

The University will continue the practices used for discarding and containment of contaminated sharps as outlined in the Environmental Health and Safety Standards (EHSS 2-6-3 and EHSS 2-6-4) as adopted on Jan 7 1988.  This document is located in all department offices.

8.0 Other Regulated Waste: Discarding and Containment

8.1 Containment

Other regulated waste (nonsharps) will be placed in closable containers which are constructed to contain all contents and prevent leakage of fluids during handling, storage, transport and shipping.

Regulated waste will be placed in containers which are labeled with the international biological hazard symbol and/or the wording "biohazard" or color-coded.

The containers will be closed prior to removal to prevent spillage or protrusion of the contents during handling, storage, or shipping.

If outside contamination of the primary container occurs it will be placed in a secondary container which meets the same requirements as the primary container.

8.2 Disposal

Disposal of all regulated waste will be in accordance with applicable regulations of the United States, Territories and Political subdivisions of States and Territories.

9.0 Housekeeping Practices

The University will insure that the work site is maintained in clean and sanitary condition.

All equipment, environmental and working surfaces will be cleaned and decontaminated after contact with blood or other potentially infectious material.

Contaminated work surfaces must be decontaminated with an appropriate disinfectant (e.g., a 1:10 solution of bleach): (1) after completion of procedures (2) immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials and (3) at the end of the work shift if the surface may have become contaminated since the last cleaning.

Protective coverings (such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment  and environmental surfaces) will be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.

All bins, pails, cans and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials will be:(1) inspected and decontaminated on a regularly scheduled basis and cleaned and (2) decontaminated immediately or as soon as feasible upon visible contamination.

Broken glassware which may be contaminated will not be picked up directly with the hands.  It will be cleaned up using a mechanical means such as a brush and dust pan, tongs or forceps.

The University Hospital will follow the policies and practices for housekeeping that are outlined in the University of Illinois Hospital Department and Clinics, Hospital Environmental Services Blood Borne  Pathogen Plan and detailed in Environmental Services Policies and Procedures (nos. 04-00, 07-00, and 09-00) all of these documents are located in the Hospital Environmental Services Office (Bldg. 949, Rm. 506).

Each laboratory is to determine and implement a written schedule for cleaning and decontamination of its' facilities. This schedule can be found in Appendix A-2 of this plan. Biohazardous waste information or pickup shall be coordinated in cooperation with:

Location Contact Campus Extension
Hospital and Clinics Hospital Environmental Services

6-3688

West Side Building Services 6-7468
East Side Building Services 5-1036
College of Dentistry Fred Chappa 6-7633
MBRB Bernie Greski 6-6963 (problems only)
BRL Jimmy Bowers 6-7052
School of Public Health West Margit Javor 3-1241
IIDD Dale Mitchell 3-1504

10.0 Laundry Practices

The University will continue to follow the policies and practices for laundry that are outlined in the UIH Laundry Policy and Procedure Manual (no. 20-0000).  This document is located in the Linen Supply Distribution Office (Bldg. 949, Rm. C950).

11.0 Hepatitis B Vaccine

All employees subject to this exposure control plan are entitled to receive Hepatitis B inoculations at the University Health Service.  All Hepatitis B inoculations must be given at the University Health Service.  There is no charge to the employee.  The employee's department Head, will pay for the inoculations.  The employee must take a completed Miscellaneous Voucher in the amount charged for the three inoculations to the University Health Service when appearing for the first inoculation.

11.1 Declination of Hepatitis Vaccine

Employees who decline the vaccinations must do so in writing, and have the right to change their mind and receive them free of charge at a later date.  The original copy of the Declination form shall be forwarded to the University Health Services for inclusion in the employees medical records.  It is recommended that the department keep a copy on file with the employee's records.

12.0 Procedure for Staff Occupationally Exposed to Blood or Body Fluids

First, determine whether or not the exposure is an "Exposure Incident" as defined on page four of this Plan.  Some events may require only appropriate sanitary measures.  For example, blood or saliva splashed onto intact skin should be washed off as soon as possible however; such an event is not an "Exposure Incident."  Exposure" to saliva that is not visibly contaminated with blood, except in dental procedures, would not be an 'Exposure Incident" even if the saliva contacted mucus membranes as in the eyes, nose etc.

Following an exposure incident, the exposed employee will immediately report the incident to his/her supervisor.  The Supervisor is to complete "Supervisor's First Report of Accidental Injury or Illness".  After an exposure incident, the University will make available to the employee a confidential medical evaluation and follow up of the incident.

The employee will report to the University Health Services during regular hours for post exposure evaluation and follow-up.  During the evenings, nights, weekends, and holidays exposed faculty/staff are to report to the Emergency Service Department.  For further details and information refer to the University of Illinois at Chicago's policy entitled Management of Employee Exposure to Blood and Body Fluids. This document is available at the University Health Service, the Emergency Services Department, and the Hospital Management Office.

13.0 Collection and Testing of Employee's Blood for HBV and HIV Serological Status

The exposed individual's blood will be collected as soon as feasible and tested after consent is obtained.  If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic testing, the sample will be preserved for at least 90 days.  If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing will be done as soon as feasible at no charge to the employee.

13.1 Collection and Testing of Employee's Blood for HBV and HIV Serological Status

In accordance with HMPP IC 3.01A, Management of Employee Exposures to Blood and Body Fluids, the source individual whose blood or body fluids are involved in the employee exposure incident shall have his/her blood collected and tested.  This testing will be done whether or not the source individual's consent has been obtained.  For further information, please refer to HMPP IC 3.01A, Management of Employee Exposures to Blood and Body Fluids.

14.0 Training

Each potentially occupationally exposed employee must be given free information and training during working hours at the time of initial assignment and at least once a year thereafter.  Additional training is needed when existing tasks are modified or new tasks are required which affect the employees' occupational exposure.

Training sessions must be comprehensive, including information on bloodborne pathogens as well as an OSHA regulations relating to this standard and the employer's exposure control plan.  The person conducting the training must be knowledgeable in the subject matter, especially as it relates to emergency response personnel.  An opportunity for a question and answer period must be part of the training session.  Material appropriate in content and vocabulary to educational level, literacy, and language of employees shall be used.

The training program will contain at a minimum the following elements:

  1. An accessible copy of the regulatory text of this standard and an explanation of its contents;
  2. A general explanation of the epidemiology and symptoms of bloodborne diseases;
  3. An explanation of the modes of transmission of bloodborne pathogens;
  4. An explanation of the University's exposure control plan and the means by which the employee can obtain a copy of the written plan;
  5. An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials;
  6. An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment;
  7. Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment;
  8. An explanation of the basis for selection of personal protective equipment;
  9. Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;
  10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials;
  11. An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available;
  12. Information on the post-exposure evaluation and follow-up that the University is required to provide for the employee following an exposure incident;
  13. An explanation of the signs and labels and/or color coding required by section 6; and
  14. An opportunity for interactive questions and answers with the person conducting the training session.
  15. A list of training materials can be found in Appendix B-1.
14.1 Additional Initial Training for Employees in HIV and HBV Research Laboratories and Production Facilities

Employees in HIV and HBV research laboratories and production facilities will receive the following initial training in addition to the above training requirements.

1. The University will assure that employees demonstrate proficiency in standard microbiological practices and operations specific to the facility before being allowed to work with HIV or HBV.

2. The University will assure that the employees have prior experience in the handling of human pathogens or tissue cultures before working with HIV or HBV.

3. The University will provide a training program for those employees who have no prior experience in handling human pathogens.  Initial work activities will not include the handling of infectious agents.  A progression of work activities will be assigned as techniques are learned and proficiency is developed.  The University will assure that employees participate in work activities involving infectious agents only after proficiency has been demonstrated.

15.0 Information

15.1 Personal Protective Equipment

University will provide the employee with information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment, including the basis for selection.

15.2 Hepatitis B Vaccine

The University will provide information on the Hepatitis B vaccine that will include: efficacy of the vaccine, it's safety, method of administration, benefit of administration, benefits associated with vaccination, and acknowledgment of free vaccine and vaccination.

The University will provide the employee with information concerning:

Emergency procedures and notifications involving blood and other potentially infectious materials, incident reporting documentation, and follow-up procedures, post-exposure follow-up evaluations following an exposure incident and explanation of signs and color-coding system required.

The University will provide the health care professional responsible for the employee's hepatitis vaccine with a copy of the Occupational Exposure to Bloodborne Pathogen standard.

The University will not make participation in a prescreening program a prerequisite for receiving the HBV vaccination.

16.0 Record Keeping

16.1 Medical Records

An accurate medical record will be maintained on each employee and kept in University Health Service.  The record will include: name and social security number, Hepatitis B vaccine status and dates or Hepatitis B vaccine declination, patient antibody testing consent, employee's decision follow-up to occupational exposure, evaluation of employee after occupational exposure and health care professional's written opinion concerning an occupational exposure.

All medical record information and pertinent information documentation will be kept confidential.  This information must comply with 29 CFR 1910.1020 and be kept for length of employment plus 30 years.

16.2 Training Records

Training records shall include the following information:

(A)  The dates of the training sessions;

(B)  The contents or a summary of the training sessions;

(C)  The names and qualifications of persons conducting the training; and

(D)  The names and job titles of all persons attending the training sessions.

Training records will be maintained for three years from the date on which the training occurred.

Attendance records of training programs meeting the requirements  of the regulations will be maintained in employee's personnel  file in their department office for review.

16.3 Manifests

Copies of waste manifests will be forwarded to and maintained by the Environmental Health and Safety Department, Health and Safety Section.  Manifests will be retained and made available to the Illinois Environmental Protection Agency for inspection and copying for a period of three years.

APPENDICES

Appendix A-1

Department List of Specific Tasks and Procedures
That Potentially May Lead to Occupational Exposure
 
 
 
 
 
 
 
 
 
 
 

             Job Classification            Tasks/Procedures
 
 
 
 
 

Appendix A-2
 
 

Department Schedule for Cleaning and Decontamination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Appendix B-1

Call the UIC Campus Biosafety Officer at 996-7429 for the list of available materials for training on the Occupational Safety and Health Administration's Bloodborne Pathogen Standard.